David Pestaña

monitoring sedation in critically ill patients : bispectral index, Ramsay and observer scales

Background and objective: Sedation is commonly required by critically ill patients and inadequate sedation may be hazardous. Traditionally, subjective scales have been used for monitoring sedation. Bispectral index has been proposed, although its utility in the intensive care unit is debated. Our aim was to evaluate the depth of sedation in intubated surgical critically ill patients by means of two sedation scales (Ramsay and Observers Assessment of Alertness and Sedation) and bispectral index. Methods: Sedation was assessed prospectively in 50 postoperative intubated patients requiring at least 24 h of sedation (35 propofol, 15 midazolam/fentanyl), every 8 h for a 24 ‐h period. The bispectral index value recorded was the mean value obtained during a 10‐min observation period, whenever the quality signal index was above 75% and the electromyographic signal was below 25%. Results: Most of the patients (78%) were oversedated (bispectral index < 60). The three sedation scores (global data) correlated significantly (P < 0.001). This correlation was lost in the midazolam group in which the patients were also significantly more sedated than the propofol group (P = 0.001). The correlation between the bispectral index and the scales in the midazolam group reappeared when the measurements with a Ramsay = 6 or an Observers Assessment of Alertness and Sedation = 1 were excluded. Conclusions: Sedation should be monitored routinely in intensive care units. The Ramsay and the Observers Assessment of Alertness and Sedation scales showed equal efficacy. Bispectral index might prove useful for discriminating between deeper levels of sedation.

Compliance with a sepsis bundle and its effect on intensive care unit mortality in surgical septic shock patients.

BACKGROUND The Surviving Sepsis Campaign was launched in 2002, aiming at a 25% reduction in mortality in sepsis during a 5-year period. We hypothesized that the compliance with an adapted sepsis bundle would improve intensive care unit (ICU) survival in a cohort of surgical septic shock patients. METHODS A retrospective, observational study was performed in surgical ICUs from two University hospitals. Seven quality indicators were considered to study the compliance with the sepsis bundle in 182 patients: (1) administration of antibiotics within 6 hours from diagnosis of septic shock, (2) initial effective antibiotic treatment, (3) adequate resuscitation within 6 hours after the diagnosis of septic shock, (4) administration of steroids, (5) use of activated protein C, (6) glucose control, and (7) protective ventilation. Univariate and multivariate logistic regression analyses were performed to make a predictive model to study the probability of survival according to the number of therapeutic guidelines fulfilled and to adjust for other predictive factors. RESULTS Compliance with individual guidelines was considered adequate in more than 60% of the cases, except in the case of glucose control. For all quality indicators, ICU survival was higher in the bundle-compliant patients. Survival (61%) was associated with the fulfilment of increasing number of therapeutic guidelines (odds ratio, 1.64; 95% confidence interval, 1.28-2.1; p < 0.001). CONCLUSIONS In surgical septic shock patients, the outcome was significantly related to the number of fulfilled therapeutic guidelines included in a sepsis bundle.

Rationale and study design for an individualized perioperative open lung ventilatory strategy (iPROVE): study protocol for a randomized controlled trial

BackgroundPostoperative pulmonary and non-pulmonary complications are common problems that increase morbidity and mortality in surgical patients, even though the incidence has decreased with the increased use of protective lung ventilation strategies. Previous trials have focused on standard strategies in the intraoperative or postoperative period, but without personalizing these strategies to suit the needs of each individual patient and without considering both these periods as a global perioperative lung-protective approach. The trial presented here aims at comparing postoperative complications when using an individualized ventilatory management strategy in the intraoperative and immediate postoperative periods with those when using a standard protective ventilation strategy in patients scheduled for major abdominal surgery.MethodsThis is a comparative, prospective, multicenter, randomized, and controlled, four-arm trial that will include 1012 patients with an intermediate or high risk for postoperative pulmonary complications. The patients will be divided into four groups: (1) individualized perioperative group: intra- and postoperative individualized strategy; (2) intraoperative individualized strategy + postoperative continuous positive airway pressure (CPAP); (3) intraoperative standard ventilation + postoperative CPAP; (4) intra- and postoperative standard strategy (conventional strategy). The primary outcome is a composite analysis of postoperative complications.DiscussionThe Individualized Perioperative Open-lung Ventilatory Strategy (iPROVE) is the first multicenter, randomized, and controlled trial to investigate whether an individualized perioperative approach prevents postoperative pulmonary complications.Trial registrationRegistered on 5 June 2014 with identification no. NCT02158923.

Adjusting positive end-expiratory pressure and tidal volume in acute respiratory distress syndrome according to the pressure-volume curve.

Background:  Management of acute respiratory distress syndrome (ARDS) patients implies the selection of the adequate ventilatory parameters, essentially PEEP and tidal volume (Vt), to prevent ventilator‐induced lung injury. These parameters should be reset as the lung injury evolves. Among the different methods proposed for the adjustment of the ventilator, the measurement of the P–V curve has emerged as a useful, although debated, tool. Our aim has been to study the relationship between the different inflection points of the P–V curve in ARDS patients, and to assess the changes in the empiric PEEP and Vt (PEEPemp, Vtemp) following its use.

Pressure-volume curve variations after a recruitment manoeuvre in acute lung injury/ARDS patients: implications for the understanding of the inflection points of the curve.

Background and objective: Although the pressure‐volume (P‐V) curve has been proposed in the management of mechanically ventilated patients, its interpretation remains unclear. Our aim has been to study the variations of the P‐V curve after a recruitment manoeuvre (RM). Our hypothesis was that the lower inflection point (LIP) represents the presence of compressive atelectases, so it should not change after lung recruitment, while the upper inflection point (UIP) reflects reabsorptive atelectases, and an effective recruitment should result in changes at this level. Methods: Two P‐V curves (quasi‐static method) separated by an RM (40 cmH2O, two consecutive manoeuvres) were plotted in 35 postoperative patients with criteria of acute lung injury/acute respiratory distress syndrome (ARDS). LIP, UIP and expiratory inflection point (EIP) were defined as the first point where the curve consistently starts to separate from the line. Results: One to six measurements were obtained per patient (73 procedures). Neither the lower nor the EIPs varied significantly after the RM (P = 0.11 and 0.35, respectively). An UIP was observed in 18 curves (25%) before the RM and disappeared on nine occasions after the recruitment. Similar results were obtained when first measurements only were analysed, and when the cause (pulmonary vs. extrapulmonary), severity of lung injury or duration of mechanical ventilation at first measurement were studied. Conclusions: An RM does not modify the LIP significantly, but induces the disappearance of the UIP in 50% of the cases in which this point is found.

Baseline Cortisol Levels, Total Proteins, and Eosinophil Count as Predictors of Hemodynamic Response to Steroid Treatment in Septic Shock

BACKGROUND Our aim was to study if baseline serum cortisol is related to the hemodynamic response to steroid treatment in septic shock patients and if the measurement of total proteins and eosinophil count improves its accuracy. METHODS A retrospective analysis was performed in 66 consecutive surgical septic shock patients receiving steroid treatment. Four criteria were chosen to define hemodynamic improvement based on the combination of noradrenaline (NA) withdrawal (at 24 and 48 hour) and an increase of the hemodynamic index (HI = mean arterial pressure/NA dose) of 150% at 24 hour and of 350% at 48 hour. The accuracy of the serum cortisol to predict the hemodynamic response to steroid treatment following the four criteria was determined by receiver operating characteristic curve analysis. RESULTS The largest area under curve was found for the NA withdrawal or an increase of the hemodynamic index >350% at 48 hour after starting the steroid treatment (area under curve, 0.686; 95% CI, 0.553-0.819; p = 0.01). This criteria was met by 35 patients (53%) and was associated with a lower mortality (25.7% vs. 67.7%, p = 0.001). However, no clear serum cortisol cutoff value for the diagnosis of adrenal insufficiency based on the hemodynamic response could be found. Neither the baseline proteins nor the eosinophils improved the accuracy of cortisol to predict hemodynamic improvement. CONCLUSION The measurement of serum cortisol in surgical septic shock patients does not accurately predict the hemodynamic response to steroids. No clear cutoff value for cortisol, alone or in combination with total protein and/or eosinophil count, can be defined to indicate steroid treatment.

Rationale and study design for an individualised perioperative open-lung ventilatory strategy with a high versus conventional inspiratory oxygen fraction (iPROVE-O2) and its effects on surgical site infection: study protocol for a randomised controlled trial

Introduction Surgical site infection (SSI) is a serious postoperative complication that increases morbidity and healthcare costs. SSIs tend to increase as the partial pressure of tissue oxygen decreases: previous trials have focused on trying to reduce them by comparing high versus conventional inspiratory oxygen fractions (FIO2) in the perioperative period but did not use a protocolised ventilatory strategy. The open-lung ventilatory approach restores functional lung volume and improves gas exchange, and therefore it may increase the partial pressure of tissue oxygen for a given FIO2. The trial presented here aims to compare the efficacy of high versus conventional FIO2 in reducing the overall incidence of SSIs in patients by implementing a protocolised and individualised global approach to perioperative open-lung ventilation. Methods and analysis This is a comparative, prospective, multicentre, randomised and controlled two-arm trial that will include 756 patients scheduled for abdominal surgery. The patients will be randomised into two groups: (1) a high FIO2 group (80% oxygen; FIO2 of 0.80) and (2) a conventional FIO2 group (30% oxygen; FIO2 of 0.30). Each group will be assessed intra- and postoperatively. The primary outcome is the appearance of postoperative SSI complications. Secondary outcomes are the appearance of systemic and pulmonary complications. Ethics and dissemination The iPROVE-O2 trial has been approved by the Ethics Review Board at the reference centre (the Hospital Clínico Universitario in Valencia). Informed consent will be obtained from all patients before their participation. If the approach using high FIO2 during individualised open-lung ventilation decreases SSIs, use of this method will become standard practice for patients scheduled for future abdominal surgery. Publication of the results is anticipated in early 2019. Trial registration number NCT02776046; Pre-results.

Variaciones hemodinámicas inducidas por la realización de una curva presión-volumen y una maniobra de reclutamiento alveolar en pacientes con síndrome de distrés respiratorio agudo

Summary OBJECTIVES: The plotting of pressure-volume curves and the performance of alveolar recruitment maneuvers are common practices in the care of patients with adult respiratory distress syndrome (ARDS), even though potentially harmful hemodynamic effects are associated with sustaining a high intrathoracic pressure. Our aim was to analyze hemodynamic and ventilatory changes related to these 2 maneuvers and to assess the short-term effectiveness of recruitment. PATIENTS AND METHODS: The patients had ARDS and were being monitored with a catheter connected to a PiCCO system. All measurements were taken in sinus rhythm and with adequate vascular filling. Values recorded during plotting of the quasistatic pressure-volume curve and the recruitment maneuver (sustained airway pressure of 40 cm H2O) were the cardiac index, mean arterial pressure, heart rate, systolic volume index, and oxygen saturation (SpO2). Blood gas measurements were recorded before the maneuvers and 15 minutes afterwards. RESULTS: All parameters decreased significantly in the 14 patients studied. The mean (SD) maximum decreases, from which all patients recovered within 2 minutes, were as follows: cardiac index, 26% (16%); mean arterial pressure, 6% (6%); heart rate, 4% (5%), systolic volume index, 21% (15%); and SpO2, 3% (3%). Significant increases in PaO2 (7% [6%]) and the ratio of PaO2 to the fraction of inspired oxygen were recorded after the recruitment maneuver (P=.016 and P=.014, respectively), but the changes were not clinically significant. CONCLUSIONS: The hemodynamic disturbances associated with the alveolar recruitment maneuver based on sustaining a high end-expiratory pressure and the minor improvement in oxygenation achieved as a result suggest that the routine use of that maneuver in ARDS patients is of questionable value.